CQC’s annual report on our work to enforce the Ionising Radiation (Medical Exposure) Regulations in England in 2023/24 has been published.
The regulations protect people from the dangers of being accidentally or unintentionally exposed to ionising radiation in a healthcare setting. Errors can happen when healthcare providers use ionising radiation to diagnose or treat people. Healthcare providers must notify CQC about incidents that meet the threshold for notification.
The report gives a breakdown of the number and type errors that CQC was notified about between 1 April 2023 and 31 March 2024. It also presents the key findings from our inspection and enforcement activity during that time.
By sharing this information, we aim to help providers and healthcare professionals identify and take action where safety improvements may be needed in their own service.
Statutory reporting has seen an upward year-on-year trend in the annual number of accidental and unintended exposures that are notified to us. This indicates that the patient safety culture in medical exposure to ionising radiation is becoming stronger.
In 2023/24, we received 819 notifications:
- 447 were from diagnostic imaging departments
- 244 were from radiotherapy departments
- 128 were from nuclear medicine departments
To provide context, during this period over 30 million diagnostic imaging examinations were carried out on NHS patients in England using ionising radiation. There were also 116,000 episodes of radiotherapy treatment in England.
This shows that notifications of errors represent a small proportion of the total examinations and treatment undertaken. Although notifications relate to incidents where there is risk of harm, most do not result in harm to patients.
As in previous years, inadequate checks about the patient’s identity by both the referring clinician and the operator were common causes of errors. The most common type of error in diagnostic imaging notifications was where a patient received an examination meant for another patient. Of the 447 notifications in diagnostic imaging, 88 (20%) involved the wrong patient being referred for a diagnostic examination and a further 27 (6%) involved the wrong patient being exposed due to an identification (ID) error.
We see that poor compliance with the regulations often results from an inadequate governance framework around radiation protection. Following inspections, we made recommendations to providers to make improvements or took enforcement action, including issuing 14 Improvement Notices to IR(ME)R employers in response to non-compliance with the regulations.
A further concern from our work continues to relate to errors caused by shortages of staff, which results in extra workload – in particular the shortages of medical physics experts (MPEs), who play an important role in quality-assuring medical radiological equipment and advising on safe doses to patients.
The report identifies recurring themes and concerns found in our work and shares practical actions for IR(ME)R employers. These are suggested actions help to improve practice and ensure patient safety.